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Known Preoperative Deep Venous Thrombosis and/or Pulmonary Embolus: To Flap or Not to Flap the Severely Injured Extremity?

Valerio, Ian M.D., M.S., M.B.A.; Sabino, Jennifer M.D.; Heckert, Reed M.D.; Thomas, Shane D.O.; Tintle, Scott M.D.; Fleming, Mark D.O.; Kumar, Anand M.D.

Plastic and Reconstructive Surgery: July 2013 - Volume 132 - Issue 1 - p 213–220
doi: 10.1097/PRS.0b013e318290fa70
Reconstructive: Lower Extremity: Original Articles

Background: Warfare-related extremity injury associated with pelvic and long-bone fractures, massive soft-tissue injuries, and high Injury Severity Scores predispose patients to venous thromboembolic events, including deep vein thrombosis and/or pulmonary embolism. The success of flap reconstruction in this setting has not been well described.

Methods: A retrospective review of war-related extremity injuries requiring flap coverage from 2003 to 2012 was completed, and the incidence of venous thromboembolic events determined. Outcomes compared included flap and limb salvage success rates and complications, such as partial/total flap failure, hematomas, and failed limb salvage.

Results: A total of 173 combat extremity injury flap procedures were performed during the period reviewed, with 50 of these flaps (28.9 percent of all cases) identified as having a venous thromboembolic event during the course of care. Preoperative or perioperative events affected 45 flap procedures (26 percent). In the 41 patients with a preoperative event diagnosis, 21 had deep vein thrombosis (51 percent), 17 had a pulmonary embolism (42 percent), and three had both (7 percent). The complication rate in these cases was 29 percent (most commonly flap or donor-site hematoma). While the total complication rate was similar between the event and nonevent groups (29 versus 20 percent; p = 0.141), the hematoma rate was significantly different (20 versus 5 percent; p = 0.009).

Conclusions: Venous thromboembolic events were detected in a high number of the authors’ combat-injured patients requiring extremity flap coverage. Despite preoperative events and risks of therapeutic anticoagulation, flap transfers were performed with high success rates and comparable nonhemorrhage complication rates between flap cohorts.


Bethesda, Md.

From the Plastic Surgery and Orthopaedic Surgery Services, Walter Reed National Military Medical Center.

Received for publication September 22, 2012; accepted January 14, 2013.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Army, Department of Defense, or of the United States Government.

Presented at the 29th Annual Meeting of the Northeastern Society of Plastic Surgeons, in Boston, Massachusetts, September 27 through 29, 2012, and Plastic Surgery: The Meeting 2012, in New Orleans, Louisiana, October 26 through 30, 2012.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

Ian Valerio, M.D., M.S., M.B.A., Plastic Surgery and Orthopaedic Surgery Services, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Md. 20889,

©2013American Society of Plastic Surgeons